Reportamos o caso de uma paciente com lesões obstrutivas nas artérias carótidas direita e esquerda, renal direita, subclávia esquerda, e ilíaca comum esquerda, tratadas percutaneamente.
Hospital São Vicente de Paulo - Faculdade de Medicina da Universidade de Passo Fundo, Passo Fundo, RS
Reportamos o caso de uma paciente com lesões obstrutivas nas artérias carótidas direita e esquerda, renal direita, subclávia esquerda, e ilíaca comum esquerda, tratadas percutaneamente.
A Arterite de Takayasu (AT) é uma vasculite crônica que envolve principalmente a aorta e seus ramos principais, produzindo sintomas isquêmicos variados devido às lesões estenóticas ou à formação de trombos1-6. O tratamento percutâneo com implante de
Paciente feminina, indígena, 25 anos, natural e procedente de reserva indígena da tribo Kaingang procurou atendimento médico com queixas de cefaléia holocraniana, de forte intensidade, acompanhada de náuseas e vômitos. Em agosto de 2002, apresentou episódio de edema agudo de pulmão (EAP). Procurou, então, atendimento médico, ocasião em que se diagnosticou hipertensão arterial sistêmica (HAS). Encaminhada para investigar causas possíveis do quadro de EAP.
Ao exame físico, estava em bom estado geral, ausculta cardíaca com ritmo regular e sopro diastólico de regurgitação no foco aórtico +++/6. Ausculta pulmonar com diminuição do murmúrio vesicular. Observou-se redução do pulso carotídeo esquerdo, pulso radial no membro superior direito em martelo d´água, não sendo palpáveis os pulsos radial, braquial, pedioso e tibial posterior à esquerda. Apresentava pressão arterial (PA) no braço direito de 200x40 mmHg, não sendo possível aferí-la no braço esquerdo pela ausência de pulso. Detectou-se sopro sistólico carotídeo bilateral, com frêmito no lado direito, sopro na artéria femoral direita e sopro abdominal. O fundo de olho apresentava estreitamento arteriolar, acentuação do reflexo arteriolar e cruzamentos arteríolo-venulares patológicos.
Ao eletrocardiograma, ritmo sinusal, freqüência cardíaca de 75 batimentos por minuto, sobrecargas atrial e ventricular esquerdas e alterações da repolarização ventricular (
O exame radiográfico do tórax demonstrou aumento da área cardíaca, aorta ascendente alongada e dilatada, sem sinais de congestão pulmonar.
Os exames laboratoriais demonstraram: uréia 53mg/dl (15-45), creatinina 1,39mg/dl (0,6-1,4), Velocidade de hemossedimentação (VSG) 101mm/h (10-20mm/h), proteína C reativa 30 (até 6,0), mucoproteínas em tirosina 8,8 mg/dl (1,7 a 5,1).
O exame ultra-sonográfico das carótidas evidenciou espessamento difuso e extenso das paredes causando, na carótida comum esquerda, estenose de 70% do seu lúmen.
Suspeitando-se da doença de Takayasu e, para confirmar a hipótese de outras lesões arteriais, a paciente foi submetida a cineangiocoronariografia, aortografia e arteriografia periférica, as quais demonstraram artérias coronárias normais, lesão grave na carótida comum esquerda e lesão discreta na carótida comum direita, oclusão da artéria subclávia esquerda no terço proximal, lesão de 60% no óstio da artéria renal direita, lesão grave no óstio da artéria renal esquerda e oclusão da artéria ilíaca esquerda no terço proximal. Ventrículo esquerdo com hipocinesia difusa e fração de ejeção (FE) de 33%. A aortografia demonstrou ectasia da aorta e insuficiência aórtica moderada a importante (
Em 26 de agosto de 2002, a paciente foi submetida a implante de
Realizou-se nova angioplastia em setembro de 2002, com implante de
Em outubro de 2002, foi realizada angioplastia para recanalização da artéria subclávia esquerda com insucesso devido à impossibilidade de ultrapassar a oclusão crônica, com a corda guia. Verificaram-se os vasos tratados previamente com resultado angiográfico mantido. Devido à presença de novo sopro sistólico na topografia da artéria carótida direita, realizou-se angiografia que demonstrou progressão da lesão ostial de discreta para moderada (70%) (
Como não houve controle adequado da atividade inflamatória (VSG 76 mm/h), foi associado ao tratamento medicamentoso o uso de ciclofosfamida na dose de 75 mg/d.
A paciente retornou em janeiro de 2003, após um ciclo de tratamento com ciclofosfamida, sendo então realizada angioplastia com implante de
Após dois anos de controle ambulatorial, com evolução assintomática, a paciente retornou em janeiro de 2005 com descompensação da pressão arterial (PA 180/100 mmHg) e VSG de 53mm/h. Usava diariamente ácido acetilsalicílico 200 mg, anlodipina 10 mg, captopril 150 mg, clopidogrel 75 mg, furosemida 40 mg e sinvastatina 20 mg. Encaminhada à angiografia renal e carotídea que demonstrou sucesso mantido do implante de
No período de 32 meses em que se acompanhou a paciente, desde seu diagnóstico inicial, observou-se diminuição da atividade inflamatória, demonstrada pela redução do VSG (9mm/h) e da proteína C reativa (<0,6), além de manutenção dos resultados dos tratamentos percutâneos. Houve, entretanto, progressão da lesão na artéria renal não tratada, apesar de haver preservação da função renal (creatinina 0,96, uréia 33).
Em abril de 2005, encontrava-se assintomática, com redução dos sinais clínicos e ecocardiográficos de insuficiência aórtica, com pressão arterial controlada (PA = 140/60 mmHg) e redução de número de anti-hipertensivos na dose diária de captopril 75mg, anlodipina 10mg e hidroclorotiazida 25mg.
A arterite de Takayasu (AT), descrita por Mikito Takayasu em 19081, é uma vasculite inflamatória, crônica, idiopática2, que compromete artérias de grande e médio calibre, particularmente a aorta torácica e seus ramos maiores e principais artérias pulmonares, além das coronárias3-5.
A fase inicial dessa vasculite caracteriza-se pelo espessamento da parede da aorta, com ou sem alterações do lúmen arterial; nessa fase, portanto, a ausência de alterações do lúmen não exclui o diagnóstico de AT6.
O processo inflamatório é destrutivo/degenerativo e leva, numa fase tardia, a alterações do lúmen arterial, caracterizadas por estenose, oclusão/trombose, coarctação atípica, dilatação e/ou aneurismas. Com freqüência predominam a estenose e obstrução, mas dilatação e aneurismas não são raros6.
A epidemiologia da AT mostra uma enfermidade rara, com incidência de 1,2 a 2,6 casos/milhão/ano7, que afeta principalmente mulheres jovens no Japão8, Estados Unidos e México, mas alguns estudos mostram freqüências próximas em relação ao sexo, principalmente no sudeste da Ásia. Menor número observa-se em brancos de ascendência européia ou norte-americana5. A localização no arco aórtico é mais encontrada em pacientes do Japão, enquanto a enfermidade mais extensa, envolvendo a aorta torácica e abdominal, predomina na Índia, Tailândia e México9. Apesar de a literatura indicar maior prevalência da AT entre os povos asiáticos e centro/sul-americanos, os autores não encontraram relatos específicos de estudo de prevalência da AT na população ameríndia.
É uma doença provavelmente auto-imune, uma vez que se demonstrou a associação da arterite com o HLA A24-B52-DR2 haplótipo10. Deve-se ressaltar que grupos étnicos diversos possuem alelos HLA diferentes associados à AT. Pacientes portadores tendem a apresentar um processo inflamatório acelerado e também maior resistência à terapia com corticóides em comparação com aqueles não portadores. Têm características heterogêneas em sua apresentação, progressão e resposta à terapia.
Segundo Sharma e cols.11 (modificado de Ishikawa12), o diagnóstico clínico da doença de Takayasu consistem em três critérios maiores (lesão da artéria subclávia média esquerda, lesão da artéria subclávia média direita e sinais e sintomas característicos de duração não inferior há um mês), e dez critérios menores (elevação da velocidade de hemossedimentação, dolorimento ou sensibilidade da artéria carótida, hipertensão arterial, insuficiência aórtica ou ectasia do anel aórtico, lesão da artéria pulmonar, lesão da carótida comum média esquerda, lesão distal do tronco braquiocefálico, lesão de aorta torácica descendente, lesão da aorta abdominal e lesão de artéria coronária). Para a elevada probabilidade de diagnóstico (sensibilidade de 92,5% e 95% e especificidade de 95% e 96%, conforme o agrupamento indiano ou japonês, respectivamente), são necessários 2 critérios maiores, 1 critério maior e 2 menores, ou 4 critérios menores11.
No caso relatado, o diagnóstico de AT confirmou-se pela presença de um critério maior (lesão da artéria subclávia esquerda) e seis critérios menores (VSG > 20mm/h, HAS, regurgitação aórtica, lesão da artéria carótida, lesão do tronco braquiocefálico e lesão da aorta abdominal), comprovados pelos exames clínico, laboratorial e angiográfico.
Apesar de a hemossedimentação ser consagrada como capaz de acompanhar a atividade da doença e considerada até excelente13 atualmente está sob questionamento, diante dos achados histológicos encontrados no ato cirúrgico e nos estudos angiográficos seqüenciais14. Deve-se valorizar outras reações da fase aguda, como bons marcadores de atividade e, desse modo, permitir a terapia ajustada. Assim, o teor de alfa-1 glicoproteína ácida, a dosagem de proteína C reativa, a alfa-2 globulina eletroforética e a haptoglobina poderão ser índices de atividade inflamatória, acompanhando a decisão terapêutica.
A angiografia é o método direto de imagem para avaliação dos vasos comprometidos, embora várias restrições se façam ao seu uso, devido à invasividade, exposição a radiações, risco de ruptura de vasos, hemorragias, infecções. Entretanto é a modalidade tradicional para o diagnóstico da AT6,15,16. A indicação da arteriografia deve ser feita para todos os pacientes e auxilia não só o diagnóstico, mas também a avaliação da gravidade do acometimento e a decisão terapêutica cirúrgica, sendo o exame pré-operatório obrigatório17. Estudos angiográficos periódicos podem demonstrar a progressão assintomática, resultando novos pontos de estenose ou formação de aneurismas. Geralmente, as estenoses predominam sobre a existência de aneurismas18.
A terapêutica da AT consiste no controle da inflamação vascular com o uso de imunossupressores isolados ou em conjunto. No entanto, na fase crônica, o objetivo do tratamento clínico nem sempre é atingido, ocorrendo, então, isquemia em diversos territórios, especialmente cerebral, coronariano, arterial periférico e renal. O envolvimento difuso, multifocal e ostial dos vasos na AT torna a revascularização cirúrgica difícil, além de estar associada a uma alta taxa de reestenose19. Dessa forma, a correção das obstruções vasculares por método percutâneo emerge como uma possibilidade terapêutica, não havendo contra-indicação mesmo na presença de inflamação arterial ativa.
As lesões obstrutivas carotídeas, renais e periféricas na AT têm sido tratadas com grande sucesso por meio de angioplastia percutânea com implante de
No caso relatado, a angioplastia com implante de
A utilidade do ultra-som intravascular para esta enfermidade ainda é desconhecida. A visibilização do comprometimento e de possível remodelamento da parede arterial, principalmente da sua extensão, dados fornecidos pelo IVUS e que não podem ser obtidos de maneira fidedigna pela angiografia, auxilia tanto na diferenciação etiológica da obstrução quanto na tomada de decisão terapêutica, possibilitando melhor definição do comprimento e do diâmetro da endoprótese, e proporcionando, presumidamente, desfechos mais favoráveis, especialmente se cogitado o uso de
Concluímos que o manejo da AT com tratamento clínico imunossupressivo associado à revascularização percutânea é uma opção em curto e médio prazos para pacientes com lesões arteriais extracardíacas significativas29-30, devendo-se considerar que a progressão da doença pode ocorrer mesmo com o uso de terapia imunossupressora. Excetuando-se a recrudescência da doença, a diminuição do corticosteróide deve ser contínua, com a retirada da medicação entre seis e 12 meses. Especula-se que uma possível alternativa a ser avaliada é o uso de
Rogério Tadeu Tumelero Rua José Bonifácio, 230/302 99070-070 – Passo Fundo, RS E-mail:
Recebido em 01/09/05; revisado recebido em 12/12/05; aceito em 01/06/06.
We report the case of a female patient with obstructive lesions in the right and left carotid, right renal, left subclavian and left common iliac arteries which were percutaneously treated.
Hospital São Vicente de Paulo - Faculdade de Medicina da Universidade de Passo Fundo, Passo Fundo, RS, Brazil
We report the case of a female patient with obstructive lesions in the right and left carotid, right renal, left subclavian and left common iliac arteries which were percutaneously treated.
Takayasu arteritis (TA) is a chronic vasculitis which affects especially the aorta and its main branches, resulting in varied ischemic symptoms due to stenotic lesions or thrombus formation1-6. Percutaneous treatment with stent implantation is feasible for the correction of stenoses of the coronary and carotid arteries, as well as of peripheral lesions, and has been increasingly considered in the management of Takayasu arteritis7-10.
Twenty-five-year-old female Indian patient, born in and coming from an Indian reserve of the Kaingang tribe. She sought medical attention with a complaint of severe holocranial headache, accompanied by nausea and vomiting. In August, 2002 the patient had an episode of acute pulmonary edema (APE); she sought medical attention and was diagnosed with systemic hypertension (SH). She was referred for investigation of the possible causes of APE.
Physical examination revealed a patient in good general conditions. Cardiac auscultation showed regular rhythm and a grade 3/6 diastolic murmur of regurgitation in the aortic area. Pulmonary auscultation showed decreased breath sounds. Reduced left carotid pulse and water-hammer radial pulse in the right upper extremity were observed. The left radial, brachial, dorsalis pedis and posterior tibial pulses were not palpable. Blood pressure (BP) was 200x40 mmHg in the right arm, and it could not be measured in the left arm due to the absence of pulse. Bilateral carotid systolic murmur with fremitus on the right side, right femoral artery murmur and abdominal murmur were detected. The funduscopy revealed arteriolar narrowing, increased arteriolar reflex and pathologic arteriovenous crossings.
The electrocardiogram showed sinus rhythm, heart rate of 75 beats per minute, left atrial and ventricular overload and alterations in ventricular repolarization (
The chest radiograph showed enlarged cardiac silhouette, elongated and dilated ascending aorta, with no signs of pulmonary congestion.
Laboratory tests showed: BUN 53mg/dl (15-45), creatinine 1.39mg/dl (0.6-1.4), erythrocyte sedimentation rate (ESR) 101mm/h (10-20mm/h), C-reactive protein 30 (up to 6.0), mucoprotein tyrosine 8.8 mg/dl (1.7 a 5.1).
Carotid ultrasound revealed diffuse and extensive thickening of the walls, causing a 70% stenosis of the lumen of the left common carotid artery.
Takayasu disease was suspected, and to confirm the hypothesis of other arterial lesions the patient underwent coronary angiography, aortography, and peripheral arteriography, which demonstrated normal coronary arteries, severe lesion in the left common carotid artery, mild lesion in the right common carotid artery, occlusion in the proximal third of the left subclavian artery, a 60% lesion in the ostium of the right renal artery, severe lesion in the ostium of the left renal artery, and occlusion in the proximal third of the left iliac artery. Left ventricle with diffuse hypokinesia and ejection fraction (EF) of 33% were observed. The aortography showed ectasia of the aorta and moderate to severe aortic regurgitation (
In August, 26th, 2002, the patient underwent a successful 6.5 mm x 13 mm Herculink (Guidant, CA, USA) stent implantation for the treatment of the ostial lesion of the left renal artery (
A new angioplasty was performed in September, 2002, with a self-expanding 8 mm x 30 mm Smart (Cordis, FL, USA) stent implantation to treat the severe lesion in the proximal third of the left common carotid artery, using an Angioguard (Cordis, FL, USA) distal embolic protection device. She was discharged with no cardiovascular events (
In October, 2002, an angioplasty was performed for recanalization of the left subclavian artery. The procedure was not successful due to the inability to cross the chronic obstruction with the guidewire. The vessels previously treated were checked, showing an unchanged angiographic result. Due to the presence of a new systolic murmur in the topography of the right carotid artery, an angiography was performed demonstrating mild to moderate (70%) progression of the ostial lesion (
Since an adequate control of the inflammatory activity was not achieved (ESR 76 mm/h), cyclophosphamide 75 mg/day was added to the treatment.
In January, 2003, after a treatment cycle with cyclophosphamide, the patient underwent a successful angioplasty with a 7 mm x 18 mm Herculink (Guidant, CA, USA) stent implantation to treat the moderate lesion in the ostium of the right common carotid artery (
After a two-year follow-up on an outpatient basis with an asymptomatic course, the patient was seen again in January, 2005 with decompensation of blood pressure (BP 180/100 mmHg), and ESR of 53 mm/h. She was on acetylsalicylic acid 200 mg, amlodipine 10 mg, captopril 150 mg, clopidogrel 75 mg, furosemide 40 mg, and sinvastatin 20 mg daily. The patient was referred to renal and carotid angiography which demonstrated unchanged successful stent implantation (performed in August, 2002) and severe lesion (80%) in the right renal artery, which was treated with a 6.5 mm x 12 mm Herculink (Guidant, CA, USA) stent implantation (
In the 32-month follow-up since the initial diagnosis, a reduction in the inflammatory activity was observed, as demonstrated by the reduction in ESR (9mm/h) and in C-reactive protein (<0.6), in addition to the unchanged results of the percutaneous procedures. However, progression of the untreated lesion in the renal artery was observed, despite preserved renal function (creatinine 0.96, BUN 33).
In April, 2005 the patient was asymptomatic, with reduction of the clinical and echocardiographic signs of aortic regurgitation, with controlled blood pressure (BP = 140/60 mmHg) and reduction in the number of antihypertensive drugs, with daily doses of captopril 75 mg, amlodipine 10 mg, and hydrochlorothiazide 25 mg.
Takayasu arteritis (TA), described by Mikito Takayasu in 19081 , is a chronic, idiopatic2, inflammatory vasculitis that affects large and medium arteries, particularly the thoracic aorta and its major branches and the main pulmonary arteries, in addition to the coronary arteries3-5.
The initial phase of this vasculitis is characterized by the thickening of the aorta wall with or without alterations in the arterial lumen. In this phase, however, the absence of luminal alterations does not exclude the diagnosis of TA6.
The inflammatory process is destructive/degenerative and, in a late phase, leads to alterations in the arterial lumen characterized by stenosis, occlusion/thrombosis, atypical coarctation, dilation and/or aneurysms. Frequently, stenosis and obstruction predominate, but dilation and aneurysms are not rare6.
The epidemiology of TA shows a rare condition, with an incidence of 1.2 to 2.6 cases/million/year7 and which mainly affects young women in Japan8, United States and Mexico, although some studies show similar frequencies as regards gender, especially in Southeastern Asia. Lower rates are observed among white European or North American descendants5. The location in the aortic arch is more frequently found in patients in Japan, whereas a more extensive disease affecting the abdominal and thoracic aorta predominates in India, Thailand and Mexico9. Although the literature indicates a higher prevalence of TA among Asians and Central/South American populations, the authors did not find specific reports of prevalence studies of TA among the Amerindian population.
This is probably an autoimmune disease, since the association of arteritis with the haplotype HLA A24-B52-DR210 was demonstrated. We should point out that several ethnic groups have different HLA alleles associated with TA. Patients with these HLA have a tendency to an accelerated inflammatory process and also to a higher resistance to steroid therapy when compared to those who do not have these HLA. Heterogeneous characteristics in its presentation, progression and response to therapy are observed.
According to Sharma et al11 (modified by Ishikawa12), the clinical diagnosis of Takayasu disease consists of three major criteria (lesion in the left mid subclavian artery, lesion in the right mid subclavian artery, and characteristic signs and symptoms with duration greater than one month), and ten minor criteria (increased erythrocyte sedimentation rate, pain or tenderness in the carotid artery, high blood pressure, aortic regurgitation or ectasia of the aortic ring, lesion in the pulmonary artery, lesion in the left mid common carotid artery, distal lesion in the brachiocephalic trunk, lesion in the descending thoracic aorta, lesion in the abdominal aorta, and lesion in the coronary artery). For a high probability of diagnosis (92.5% and 95% sensitivity, and 95% and 96% specificity, according to the Indian or Japanese grouping, respectively), two major criteria, one major criterion plus 2 minor criteria, or 4 minor criteria are necessary11.
In the present case, the diagnosis of TA was based on the presence of a major criterion (lesion in the left subclavian artery) and six minor criteria (ESR > 20 mm/h, systemic hypertension, aortic regurgitation, lesion in the carotid artery, lesion in the brachiocephalic trunk, and lesion in the abdominal aorta) confirmed by clinical, laboratory and angiographic tests.
Although the erythrocyte sedimentation is a well-established test to follow the activity of the disease and even considered an excellent test13 is currently been questioned, because of the histological findings of specimens obtained during surgery and of sequential angiographic studies14. Other acute phase reactions should be valued as good activity markers and thus enable an adequate treatment. Therefore, alpha-1 acid glycoprotein, C-reactive protein, electrophoretic alpha-2 globulin, and haptoglobin levels could be indicators of inflammatory activity, thus facilitating therapeutic decisions.
Angiography is the direct imaging method to evaluate the affected vessels, although several restrictions apply to its use due to the invasiveness, exposure to radiation, vessel rupture risk, bleedings and infections. However, it is the traditional modality for the diagnosis of TA6,15,16. Arteriography should be indicated for all patients, not only facilitating the diagnosis, but also the assessment of severity of the disease and the choice of surgical treatment, thus being a mandatory preoperative test17. Periodic angiographic studies may demonstrate an asymptomatic progression resulting in new sites of stenosis or aneurysm formation. Stenoses are usually more frequent than aneurysms18.
The treatment of TA consists of the control of vascular inflammation with the use of immunosupressors alone or in combination. However, in the chronic phase, the objective of the clinical treatment is not always achieved, and ischemia in several sites occurs, especially in the cerebral, coronary, peripheral arterial and renal territories. Diffuse, multifocal and ostial vessel involvement in TA makes the surgical revascularization difficult, in addition to being associated to a high rate of restenosis19. Thus, the percutaneous correction of vessel obstructions emerges as a therapeutic possibility with no contraindication even in the presence of active arterial inflammation.
Obstructive carotid, renal and peripheral lesions in TA have been successfully treated with percutaneous angioplasty with stent implantation, which has proved safe and with a good cost-benefit ratio, thus being an alternative for patients at high surgical risk20, despite the morbidity and mortality associated with the disease and the procedures21. The experience with the percutaneous treatment of TA described in the literature is limited to case reports. Takahashi et al reported the first case of multiple stenting in all branches of the supraortic arch, however without the involvement of the renal arteries, with a two-year follow-up and favorable outcome22.
In the case reported, angioplasty with stent implantation was successfully performed in the renal and carotid arteries. Procedures in the carotid arteries were performed with a distal embolic protection device, with the purpose of reducing the risk of stroke during endoprosthesis implantation23. Endarterectomy is accepted as the standard treatment for revascularization of extracranial occlusive atherosclerotic lesions, validated by means of randomized controlled studies which demonstrated the superiority of endarterectomy over the pharmacologic treatment. However, in the past few years, the utilization of stents for the treatment of atherosclerotic stenoses of the carotid arteries has emerged as an alternative to endarterectomy24. The endovascular treatment has been corroborated by randomized studies as a treatment as efficient as endarterectomy. The SAPPHIRE23 study designed for the treatment of patients considered at high surgical risk according to Sundt25 criteria demonstrated similar results for the surgical and percutaneous treatment when the distal cerebral embolic protection device was used. TA and atherosclerotic disease are known to be distinct diseases, but the risk of the surgical procedure is not reduced in TA. Additionally, although TA does not favor the presence of plaque fragments, the use of the distal protection device is justified by the possibility of thrombus formation with distal embolization, which should be prevented. Thus, the patient at issue was considered at high risk due to the clinical presentation with acute pulmonary edema, aortic valve involvement, left ventricular dysfunction and poor control of blood pressure. Given the rare presentation and its pathogeny, no studies comparing endarterectomy and stent implantation in patients with Takayasu arteritis are available. However, the clinical control of inflammation with immunosupressors is known to provide a better prognosis for patients with this condition when undergoing the procedure.
The usefulness of intravascular ultrasound (IVUS) for this disease remains unknown. Information on the visualization of the involvement and possible remodeling of the arterial wall, especially of its extension, provided by IVUS and which may not be reliably obtained by angiography, helps both differentiating the etiology of the obstruction and making decisions regarding the treatment, thus enabling a better definition of the length and diameter of the endoprosthesis and presumably more favorable outcomes, especially when the use of drug-eluting stents is considered. As occurred with the coronary atherosclerotic disease, the routine utilization of stents may contribute for a better understanding of TA. Stent implantation in the right common carotid artery was monitored by intravascular ultrasound to evaluate the characteristics and composition of the obstructive lesion. The renal arteries were treated at different moments, but always showed significant clinical manifestation. Current studies on the treatment of renal artery stenosis, mainly on percutaneous revascularization, comprise patients undergoing the procedure for the management of systemic hypertension and take into account the probability of improvement of blood pressure and/or renal preservation26. Unfortunately, many studies suggest that revascularization of the renal artery for the treatment of atherosclerotic stenosis of the renal artery seldom cures systemic hypertension; cure rates of percutaneous transluminal angioplasty, stent implantation, and surgery range from 6 to 21%27. In this case, we observed both a better control of the blood pressure and preservation of the renal function. Regarding recanalization of the left subclavian artery, success is highly related to specific characteristics of the chronic occlusions and technical aspects. Characteristics related to the lesion are the total occlusion time, the extension of the lesion and the morphological aspect, unknown under the angiographic and intravascular ultrasound aspects. The ability to cross the lesion with the guidewire is the determinant technical factor for success28. In this case, the guidewire could not cross the occlusion. The chronic process installed and the diffuse disease associated with the aggressive inflammatory activity contribute for the failure of the recanalization. In chronic occlusions of the coronary arteries, in addition to specific guidewires, other techniques are used, such as rotational atherectomy, laser and radiofrequency. Despite being useful in a small group of procedures, these techniques are not superior to the use of specific hydrophilic guides. Additionally, the inflammatory character of TA may contribute to increase the rates of complications, the most important of which is arterial perforation. The left common carotid, renal and aorta arteries were assessed by intravascular ultrasound using 30-MHz and 9-MHz probes, respectively. The arteries treated were patent and showed no proliferative lesions.
We conclude that the management of TA with immunosuppressive clinical treatment associated with percutaneous revascularization is a short and mid-term option for patients with significant extracardiac arterial lesions29-30. The progression of the disease, even with the use of immunosuppressive therapy, should be considered. Except when recurrence is verified, the steroid dose should be continuously decreased, with discontinuation between six and 12 months. A possible alternative to be evaluated is the use stents coated with drugs which inhibit endothelial proliferation by means of cytostatic and cytotoxic mechanisms, such as sirolimus and paclitaxel, currently used in the treatment of atherosclerotic coronary lesions. Patients with more prominent endothelial proliferation, such as those with diabetes mellitus and chronic renal failure are proved to obtain greater benefits. Even with higher costs of the procedure, the association with the use of intravascular ultrasound may be useful to differentiate atherosclerosis from specific characteristics of TA, thus adding information and guiding the percutaneous treatment.
Rogério Tadeu Tumelero Rua José Bonifácio, 230/302 99070-070 – Passo Fundo, RS, Brazil E-mail:
Manuscript received September 1, 2005, revised Manuscript received November 8, 2005; accepted November 11, 2005.